Across Country Lines: Tackling Global Chronic Disease

More than 350 million people worldwide are living with diagnosed diabetes, according to The Lancet. The disease, and disease-related complications, receives considerable media attention in the U.S, but, in fact, 80 percent of diabetes-related deaths occur in low to middle-income countries outside of the U.S. In these countries, awareness about the severity of the disease and education about ways to prevent type 2 from developing are less prominent even though mortality rates are higher.

On Tuesday, I will be covering a session that highlights a few of the global strategies being employed to give diabetes the attention it needs to raise public consciousness. I was selected to participate in GBCHealth's Annual Conference as a member of the Social Media Corps- a group of students with interests in global health, nutrition and medicine that will be live tweeting and blogging from the conference. South Africa’s First Lady, Madam Bongi Ngema-Zuma, who created the Bongi Ngema-Zuma Foundation in July of 2010 will share what her country is doing to combat rising rates of non-communicable diseases like diabetes. Madam Bongi Ngema-Zuma has said, “My vision is to see a South Africa where diabetes ceases to be a killer due to lack of awareness.”

As a health communications concentrator in my public health studies, I know that awareness is the first step in creating behavior changes. Awareness is also often the first step in securing funding needed to develop policy changes and create programs to address the health issue.

And diabetes is a serious health issue in South Africa; currently 1.5 million South Africans are living with the disease with more than twice that number at risk for developing the disease in the coming years. Yet, many are unaware of the disease’s signs or preventative actions. The First Lady created her Foundation with clear objectives, namely: 

·      To increase awareness: That is send out a loud and clear message locally and globally

·      To collaborate with strategic partners and key stakeholders involved in diabetes to spread knowledge

·      To empower rural, urban and vulnerable communities

·      To support training and empowerment of community health programmes

The First Lady’s foundation has already made great strides in the past two years but I look forward to learning more about what’s in store for the Foundation’s future. The foundation has focused on building partnerships, increasing opportunities for diabetes testing and diagnosis, convening key stakeholder meetings such as the Diabetes Leadership Forum, and providing diabetes education to citizens thus far; important steps in building national awareness.

I have read much about prevention and awareness campaigns for non-communicable diseases in the U.S. and I couldn’t help but think how similar some of the tenants of the First Lady of South Africa’s campaign are to the First Lady of the United States’s Let’s Move campaign to prevent childhood obesity. Nearly a world apart, but people are still in need of many of the same tools and resources to make healthy choices and protect their health. While the barriers may vary across country and community lines, we can learn much from similar efforts to promote health for all. I’m looking forward to hearing what Madam Bongi Ngema-Zuma’s Foundation has in store.

Why should you care about the farm bill?

Several weeks ago, I had the opportunity to attend an event at Boston’s Museum of Science called “Let’s Talk About the Farm Bill.” Speakers included Marion Nestle, PhD, professor of nutrition and public health at NYU; Representative Chellie Pingree of Maine, member of the House Committee on Agriculture; and Tim Griffin, PhD, Director, Agriculture, Food and Environment Program from the Friedman School of Nutrition Science & Policy (my school!). That’s quite a line-up for a food policy junkie. It would have to be in order to get a full-time graduate student to sit through a day of lectures on a Sunday.

I imagine for most of us who attended, Marion Nestle was the main draw. In addition to being a professor, she has published several books (most notably Food Politics and What to Eat) and is a contributing writer to both her own blog and the Los Angeles Times. (This makes me feel very guilty for the one-month lapse in my own posting!)

[Side note: Another draw was free admission to an accompanying exhibit at the museum prior to the farm bill session titled “What I Eat: Around the World in 25 Diets,” adaped from a book of the same moniker. The exhibit walked us through a typical day’s worth of food for individuals around the world, ranging from a 5,800 calorie/day for a man in Yemen to the 1,700 calorie/day for a teen in China. Differences in types of foods consumed and daily physical activity are striking between countries and cultures. I encourage you to check it out!]

Back to the farm bill… Farming may seem like a distant cousin to our food supply these days. Many people go days and weeks without consuming anything that even loosely resembles its origin in a field or orchard. But it’s important to remember that nearly all food still has its roots in farming and farm policy dictates much of what is available for us to eat- oh, and how much it costs. Attending this talk made me realize the importance of helping people to understand how this bill affects every citizen in this country, and why we should all be paying attention to it.

Marion Nestle started off the “talk-in” with an overview of the bill. She presented an impressive deck that effectively covered an entire semester of US Food Policy 101 in about twenty minutes. The bill is incredibly confusing (I counted the word “confusing” used at least 7 times during the talk), but is also incredibly important for reasons that extend beyond even our food system. It is so comprehensive that I feel we all should know at least the basics of this massive bill and how we can become advocates for the issues that are most important to us. I’ll do my best to highlight the reasons why the farm bill touches all of our lives, even if some of us have never heard of it before.

1.    The last farm bill was authorized in 2008, making it ready to be re-authorized this coming year (although, it’s an election year which means Congress won’t be doing much re-authorizing of anything so don’t hold your breath).

2.    The farm bill largely dictates what Americans eat, so much so that some experts like Michael Pollan want to change its name to ‘The Food Bill.” Thus, if you care about food, you should care about the farm bill.

3.    The farm bill is huge- the last iteration was 663 pages and encompassed hundreds of programs that cost taxpayers around $85billion/year. If you care about where your tax dollars go, you should care about the farm bill.

4.    There are 15 titles in the bill including some of the biggies: commodities, credit and crop insurance.

5.    The bill’s complexity is what makes it so hard for the average American to comprehend, which makes the process less about democracy and more about lobbyists and special interest groups who are uniquely informed about their specific title (or titles) of interest. Agribusiness lobbyists spend upwards of $120 million per year (according to opensecrets.org). If you care about democracy, you should care about the farm bill.

6.    Current farm bill policy tends to favor

a.     Big, intensive farms

b.     The South and Midwest regions

c.      Animal feed crops (such as corn/soybeans)

d.     Biofuels (corn for ethanol)

e.     Overproduction

7.    One of the largest chunks of farm bill spending goes to nutrition assistance programs like SNAP, which has experienced significant growth in recent years mostly attributed to the economic downturn. In 2011, $72 billion of the farm bill went to SNAP, making up 84% of total farm bill expenditures. If you care about preserving our safety net for low-income Americans, you should be concerned about the farm bill.

8.    The bill has received criticisms in recent years because farmers have been very profitable, but are still receiving price supports that have carried over from the Great Depression and direct payments in years where they are meeting or exceeding their target prices

10. 40% of corn grown in the U.S. goes to ethanol production, not food, which has caused spikes in world food prices. If you care about fuel prices, you should be concerned about the farm bill.

For someone who already had a fair amount of knowledge about this topic, I felt that I also learned a lot that day. I’m grateful to the speakers who shared their time and expertise with us to further the understanding of the public. Dr. Nestle emphasized that at its heart, the farm bill is about democracy. We all vote with our fork and have the power to choose the kind of food system we want.

The first step in making your voice heard is getting your facts straight and outlining your priorities.  The second is talking to your Congressman about the changes you’d like to see in the 2012 farm bill.  You may also want to ‘like’ the page ‘Understanding the Farm Bill: A Citizen’s Guide to a Better Food System’ to stay informed.

Head on over to InsideTracker to read about my eye-opening and humbling experience. Proof that even those who are knowledgeable of good nutrition aren't immune to the pitfalls of our modern diet!

Check back with InsideTracker from time time for updated posts about all the latest in nutrition science.

Eating Well On the Cheap

My Affinity for Near-Poverty

My father jokes that I am only attracted to jobs that don’t pay well. Looking at my track record of employment over the last two decades, I finally acknowledged that he may be onto something. Through my summers in junior and senior high school, I worked at a non-profit camp for mentally and physically challenged youth; I became an AmeriCorps member with a whopping $11,000 annual paycheck once I had a college degree; I got my first “grown-up” job at an anti-hunger non-profit before going back to graduate school for public health, a field known for minimal pay (…if one more person asks me “Why don’t you just become a doctor?!"). Last summer, I turned down several paying internships to intern without pay for the federal government; and am now working part-time while finishing my degree at… you guessed it… a non-profit health consulting company!

So the man has a point. But I can say that all of these years of scraping by with meager paychecks has taught me a thing or two about being cheap thrifty. Especially when it comes to eating healthfully, something I have rarely sacrificed, no matter how limited my funds (except for those two weeks I survived solely on peanut butter sandwiches in July of ‘07). A common argument I hear from twenty-somethings unable to make dietary change is, “It’s just too expensive to eat healthy.”

The potential health costs of poor nutrition have already been highlighted on this blog and others ad nauseam, so I’ll spare you that. Instead, I’d like to focus on just how much it costs to eat a healthy, whole-foods diet. (For simplicity, we’re going to ignore additional considerations of locally grown, grass-fed, free-range or organic foods. One step at a time, people.) At first, this may seem like a question that has no real answer since food can be a highly elastic good; availability of certain foods can vary seasonally; and taste preferences, marketing and time constraints largely dictate what foods Americans choose to eat. But, there is a simple answer to how much it actually costs to eat a nutritionally balanced diet in America. And the government has already done all of the work for you to figure this out.

The Thrifty Food Plan

The Thrifty Food Plan (TFP) is one of several food plans created by the government to determine funding levels for federal food assistance programs. Did you ever wonder how the USDA decides how much supplemental food income a family of four needs when distributing monthly SNAP benefits? (Of course you didn’t! Only us food policy nerds lay awake at night thinking about these things!) It’s actually quite a complicated process (which gives me some relief that Tom Vilsack is not pulling these numbers of out of a hat). The TFP is designed to be the cheapest possible food plan that would provide adequate nutrition for an individual or family, and uses foods that people are actually consuming.

The TFP is calculated monthly using data collected for the consumer price index (CPI) and is updated every five years by the USDA. (Note that USDA updates the budget constraint for inflation every five years, but the budget has not been reviewed since the 1970s.) The CPI tells us changes in the prices paid by consumers for a representative ‘basket of goods and services.’ The USDA’s TFP goes even further than the CPI to represent a national average of expenditures (four-person household consisting of an adult couple and two school-age children) adjusted for other household sizes through the use of a formula reflecting economies of scale (ie. the fact that costs of food production fall as output increases).

The plan can be amended according to:

• Spending:  Compare your monthly spending to the official TFP cost target
• Broad food categories:  Daily servings of dairy, meats, grains, fruits, and vegetables   
• Distance from current consumption:  A bigger number means greater deviations from the foods that low-income Americans currently choose
• Energy:  Compare your daily calories to the recommendation for maintaining healthy weight
• Macronutrients:  Daily grams of carbohydrates, fats, and protein
• Micronutrients:  Compare your calcium or sodium to the recommendations

As of February 2010, the cheapest monthly food basket that would meet The 2010 Dietary Guidelines forAmericans, according to age group/sex cost:

• $168.40 for 19-50 year-old males
• $149.90 for 19-50 year-old females
• $509.70 for a couple, 19–50 years old, with two children between 2–3 years old and 4–5 years old

By this point, you might be wondering, what on earth are these people eating that costs less than $170/month?! Does this plan necessitate extreme couponing? 

 (photo source)

I’ll be honest, it’s not gormet. But it’s also not the fast food or heavily processed food that many people associate with cheap diets. A sample weekly shopping list for an adult male on the TFP, as of February 2010, would cost around $38 and include the following:

4½ pounds (lb) of grains (rice, bread, pasta, and cereal)
2½ lb of potatoes
5 lb of other vegetables
2 lb of canned or dried beans
6½ lb of fresh fruit
1¾ lb of fruit juice concentrate
11 lb of dairy products
2½ lb of chicken
½ lb of beef or pork
¼ lb of nuts
2–3 eggs (purchasing 1 dozen eggs once/month)
2 lb of oil, salad dressings, spices, condiments, misc

*Note that eating according to this plan would necessitate cooking. What else are you going to do 4½ lbs of dry pasta and 2lb of dried beans? A few basic cooking necessities are assumed, such as the ability to boil water, access to a stove or hot plate, and owning a skillet and pot at the bare minimum.


Cooking also involves time, something that us multi-tasking twenty-somethings have in short supply. A study published in the Journal of Nutrition calculated the cost of cooking time by using a formula developed at the University of Warwick in England, using the per capita income, the hourly wage, and the tax rate. The study found that if it takes 9 hours to prepare food weekly, which would actually cost about $150/week in time. (If you’re like me and like to cook while listening to music, which inevitably leads to using your tongs as a microphone, then add another hour or two to this estimate.)

 (If anyone is looking for a gift for me for my next birthday... I'm just sayin'.)

What’s not included on this plan? Eating out. In 2001–2002, eating one meal outside of the home would raise TFP prices by 7 percent- yikes! And how in the world is there no allotment for coffee? Coffee is right up there with oxygen on my list of basic necessities.

While the shopping list above is certainly not flashy (there will be no smoked salmon for lox bagel breakfasts on the TFP), there’s much that you could do to spice up your weekly menu, while still hovering at or below your budget line. If your food budget is tight, challenge yourself to be creative with your limited resources, and remind yourself that you’re doing your body a favor by eating whole foods rather than fast food, even if it means cutting back on quantity at times.

Many struggling twenty-somethings like myself have a bit more wiggle room than the low-income families that this plan was designed for. We can splurge on a few high quality spices such as cumin or tarragon- a little goes a long way when it comes to seasoning meats, bean dishes or vegetables. (And for God’s sake, buy yourself some coffee!) I’m only using the TFP as an example of how one could eat a healthy, whole-foods diet that meets basic nutritional needs in order to challenge the argument that it simply isn’t possible. 

Let's Move Blogpost

Check out my blogpost on the Let's Move blog! After interning with the National Park Service this past summer, I drafted a post about how we helped the staff get moving using the Presidential Active Lifestyle Award (PALA) Challenge.

Read more here. 

What are the chances Michelle Obama will read my post?!

(photo source)

A Collaborative Approach to Improved Health Outcomes

Last week I had the opportunity to attend the 139^th American Public Health Association (APHA) conference in Washington (thank you, Tufts!). The theme for this year’s conference was ‘Healthy Communities Promote Healthy Minds  & Bodies.’ As evidenced by its title, the conference focused on prevention strategies that create opportunities for people to stay healthy. Sessions I attended discussed implementing school wellness policies in Indiana, using a social marketing campaign to promote physical activity at the Cleveland Clinic in Ohio, and text-messaging campaign to help teen girls in Texas get moving (among others).

Historically, the field of public health has differentiated itself from medicine in its focus on preventing disease, while leaving medicine to treat disease. These seemingly like-minded professions have a troubled history.  At one time, public health and medicine were seen to be overlapping professions that worked together to support the interest of the public. In fact, physicians were a dominant presence in the early history of the American Public Health Association. At the turn of the century, physicians constituted up to 80% of the association’s membership.

But rifts between their ideologies started early- and still run deep. The president at the First Annual Meeting of the American Public Health Association in 1873 said,

“If the medical profession was as much devoted to the practice of the art of preventing as it is in curing disease, there can be no doubt that many diseases which now decimate communities would disappear altogether, and the larger number would have the mortality set opposite them greatly reduced.”

I’ll admit, my course-work thus far has painted a picture of the medical community as being sometimes short-sighted, focusing on providing acute (and very expensive) care rather than investing in infrastructure and capacity-building in communities that would prevent the development of disease or treat disease before it reaches a level of severity. Public health is often focused on the health of the population at large and may promote interventions that are best for all people, and not one unique individual. It's clearly more difficult for a physician to take a population-based approach when a patient's life or well-being hangs in the balance.  For example, many public health professionals advocate for the judicious use of antibiotics, asking physicians to prescribe them less frequently to prevent the development of 'superbugs' that are resistant to traditional drugs. But it's much harder for a doctor to say 'no' to a mother with a screaming infant who wants an antibiotic to justify missing work, even if her child's illness is viral.
         Public health also tends to focus on the social and environmental determinants of health; looking at factors such as affordable health insurance, access to healthy foods, and safe sidewalks to promote walkable neighborhoods. As one might imagine, these factors are largely determined by financial and political forces. For more on public health's emphasis on sociocultural determinants of health, check out Cornel West's keynote speech from last year's conference in Denver.

(Dr. West is from the Center African American Studies and the Department of Religion at Princeton University)

My perspective is clearly biased since I chose to pursue a career in public health, rather than becoming a clinician, so take my ramblings with a grain of salt. Plenty of medical doctors and nurses are also interested in preventative measures (my favorite is Dr. Esselstyn), but they often receive little formal public health training. One thing I noted at the APHA conference was the diversity of careers represented at the APHA Expo- a large exhibit hall at the Convention Center that showcases all things public health. Besides the standard government booths (National Institutes of Health, Centers for Disease Control, Department of Health and Human Services, etc.), I noticed medical professionals, pharmaceutical companies and supplement manufacturers in attendance. 

My initial reaction, when walking past the very large, shiny and prominent GlaxoSmithKlein booth was to a) cringe and b) think, 'What are you doing here?' Public health is about changing habits and environments to improve population health, not promoting expensive drugs that are often unnecessary for conditions that can be controlled or reversed through lifestyle changes! How short-sighted of me.

Medical technology and pharmaceuticals have improved the lives of countless (arguably all) humans over the past century. A major component of public health is ensuring all persons, regardless of income, immigration status, race or insurance can access vaccines to prevent the spread of communicable diseases. I often advocate for such policies and it would be unfair not to give credit to the pharmaceutical companies who develop, promote and distribute these vaccines. I’m currently working on developing a promotional campaign for HPV vaccination in both adolescent boys and girls to reduce the incidence of cervical and anal cancers. (Michele Bachman, I will never forgive you for the damage you've done to this cause.) How could I not acknowledge the important role MERCK played in researching and developing such an important prevention measure?

One of the most interesting sessions I attended discussed ethical considerations of direct-to-consumer advertising for pharmaceutical companies in the U.S. and New Zealand (the only countries that currently allow this practice). I have several friends who work in pharmaceutical advertising, so I was particularly interested in this session. I try to think of pharmaceutical advertising companies as much more than ‘high level drug dealers’ as they were once described to me, but their sometimes controversial practices have left me skeptical at times.

Timothy Mackey, a PhD student at the Institute of Health Law Studies at UC San Diego led the session, titled ‘Global regulation and public health issues associated with interactive internet media.’  He shared that there has been a 330% increase in pharmaceutical marketing from 1996-2005. Woaah. Direct-to-consumer advertising can have several benefits, including empowering consumers to become more informed about their health, increasing adherence to life-saving medications, educating consumers, and raising awareness of the prevalence of certain conditions in the population that people may be uncomfortable addressing with a primary care physician. How many more people felt inspired to treat their erectile dysfunction once Jimmy Johnson endorsed Extenze?

But direct-to-consumer advertising of pharmaceuticals can have negative consequences too. Increasing awareness can also lead to increased demand for drugs which may not be necessary (see: overprescription of antibiotics).  Was Jimmy Johnson’s sex life ­really that bad before? We’ll never know. Nor do we want to. But now, health care costs are likely to rise as a result of demand for Extenze. Secondly, marketing can be deceptive. It can misrepresent the effectiveness or application of a drug. I mean, who could mistrust a cartoon bumble bee selling nasal spray?

You almost can’t even hear the laundry list of potential side effects that the narrator reads at speeds that rival the micromachines guy. How does he talk so fast?!

Lastly, it’s incredibly hard to regulate this industry, which may be why it is so profitable. Direct-to-consumer advertising is only legal in the United States and New Zealand, but you can bet that citizens in other countries are accessing the Nasonex bee’s YouTube ads. In this digital age, policing of pharma messages is more challenging than ever. All of the top 10 pharma companies are involved in social media. According to Timothy, 80% of them have YouTube channels and some type of mobile application developed. 

I have beef with marketing drugs that treat otherwise preventable conditions. No lie, as I’m writing this post, I'm watching an advertisement for Lipitor. So perfect. Let’s look at Lipitor. Lipitor is a cholesterol-lowering medication. It lowers both your bad cholesterol (LDL) and trigylcerides. Its website tells consumers that, “In fact, about every 34 seconds in the US, someone has a heart attack, and 80% of those people have high cholesterol.” I don’t doubt the accuracy of these claims. But I do doubt that taking Lipitor is the best way to combat these devastating statistics. You know what else lowers cholesterol for many people? A whole foods, plant-based diet and regular physical activity. I don’t make this stuff up.

Therein lies the distinction between a public health and medicine. Perhaps the take-away here is that public health, medicine, and pharmaceutical companies are all truthfully aiming for the same thing. We all want to reduce the burden of disease, but we have different ideas about how to do that. Who’s to say that one approach is better than the other. The important thing is to recognize each field’s unique contribution and to look for ways to collaborate. (A great example is the Cleveland Clinic's GoFit Cleveland campaign, which was sponsored by the clinic but provided access to local YMCAs and other weight loss supports for low-income residents to improve population health.)
        The biggest lesson I learned at APHA (besides how to collect obscene amounts of swag) is that the health problems our world faces are enormous. And there really are no good guys or bad guys. If we work together, and play to each other’s strengths, solutions for the challenges we face seem all the more achievable. 

Yesterday was Food Day

You might be thinking, hold up, isn’t every day? To which I would answer, technically, yes. You do think about, prepare and eat food every day.  But not everyday is Food Day.  See the distinction?

What is Food Day?

You may be slightly more familiar with Food Day’s siblings: Earth Day, Mother’s Day, Father’s Day, and Valentine’s Day. Well similarly, Food Day was created to celebrate something that is invaluable, but often gets little recognition.  It’s so easy to breeze through our days just trying to leave the apartment with a cell phone, wallet AND keys in tow (WHY is it so hard to remember all three at the same time?) that sometimes we need to designate a special day to reflect on the really important things that often get lost in the shuffle.

Food Day is the brainchild of the Center for Science in the Public Interest (CSPI), the nonprofit watchdog group that has championed other food-related issues such as menu labeling and reducing junk food marketing to kids. (If you don’t already subscribe to their Nutrition Action Healthletter, I recommend doing so; it's an inexpensive source of high-quality nutrition information. But beware of enumerable Walter Willett quotes. Is there really no other expert to quote?) According to its website, Food Day “seeks to bring together Americans from all walks of life—parents, teachers, and students; health professionals, community organizers, and local officials; chefs, school lunch providers, and eaters of all stripes—to push for healthy, affordable food produced in a sustainable, humane way. We will work with people around the country to create thousands of events in homes, schools, churches, farmers markets, city halls, and state capitals.” The initiative boasted Senator Tom Harkin (D-IA) and Representative Rosa DeLauro (D-CT) as the Honorary Co-Chairs, to add a touch of street cred.

The Center for Science in the Public Interest kicked off its inaugural Food Day with a fresh and healthy lunch right in the middle of Times Square. Guests included NYU’s food policy expert Marion Nestle, Mario Batali (needs no introduction), the Food Network’s Ellie Krieger, Michael Jacobson (director of CSPI), Tom Farley (director of New York City’s Health Department), Morgan Spurlock (think Super Size Me), and Josh Viertel (President of Slow Food USA) among others. Big thanks to CSPI for answering the 'Who would you invite to a dinner party if could invite anyone in the world?' question for me. I've always struggled with that one.

 (photo credit: Food Politics)

Food Day was celebrated in different ways across the country, reinforcing ing the multidimensional qualities of food. In the Boston area, both Harvard’s Food Law Society and Boston’s Museum of Science hosted screenings of the film ‘Food Fight’, while the Friedman School’s student council along with Share Our Strength’s Cooking Matters Massachusetts hosted a screening of another food-related film, ‘Forks over Knives.’

Boston’s Mayor Menino stopped by the Friedman School to talk about the current state of the city's food system and share some future initiatives in the works. This was my first time meeting Mayor Menino, the man who championed banning sugar-sweetened beverages from government property (with much support from the Boston Public Health Commission), and it was a privilege.  He spoke of the success of the city’s Bounty Bucks program, which increases the amount of money low-income families can use to purchase fresh fruits and vegetables at farmers’ markets, and also shared his new-found affinity for soy bacon thanks to Clover food truck’s innovative mobile food options. He also shared that of all the battles he's fought as mayor, removing soda from vending machines has been the toughest. (And this from a guy who was in office during Boston's Big Dig...). After his talk, I stormed the stage to shake the hand of a man who doesn't shy away from a challenge, and sees the importance in building alliances with groups such as The Food Project and the Friedman School to promote healthy food access for all of Boston’s residents.

 (photo credit: my crappy iphone camera)

It’s days like yesterday that assure me that I’m in the right field. Food touches so many aspects of our lives- including social, environmental, and cultural. At the most basic level, it keeps us alive. But it is so much more than that. Because of its impact on trade relations, political agendas, and job creation, the food industry commands great influence in our society. Let’s give the food system the respect and attention it deserves on more than just one day each year, shall we? October 24th was an awefully good start.